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General NPI Number Information
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NPI Number | 1679720726
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Entity Type | Individual
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Provider Name | WAYMOND JAY PETTIT M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/20/2008
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Last Update Date | 08/20/2008
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Provider Practice Location Address
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Address Line | 3620 S TAYLOR RD
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City | DECATUR
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State | IL
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Zip | 62521-9015
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Country | US
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Telephone | 217-454-0022
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Fax |
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Provider Business Mailing Address
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Address Line | 451 E 1000 N
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City | LA PORTE
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State | IN
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Zip | 46350-8638
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Country | US
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Telephone | 219-778-8524
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Fax | 219-778-8534
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 036051290
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License Number State | IL
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